Saint Agnes Hospital Baltimore, Maryland Community Health Needs Assessment & Implementation Strategy Introduction Beginning in 1862, and continuing over the last 150 years, Saint Agnes Hospital has been providing for the health care needs of Southwest Baltimore and surrounding communities. Saint Agnes Hospital conducted the community health needs assessment (CHNA) as an update to its prior assessment last conducted in 2008. The CHNA was conducted for Saint Agnes primary and secondary service areas, a geography that includes Southwest Baltimore City and Baltimore County, Eastern Howard County, Southeast Carroll County and Northern Anne Arundel County. While retaining elements of the 2008 assessment process, this CHNA was retooled to address the assessment and implementation strategy requirements as outlined in the Health Care Affordability Act and 501(r)(3) regulatory requirements. As an independent health care provider in the community, Saint Agnes completed its assessment individually and collaborated with the local health jurisdiction in the formulation of its implementation plan. The health needs present in the Saint Agnes Hospital service area are as diverse as the communities served. The assessment highlights each community individually, identifying the risk factors and health needs that are unique to that specific population. While Saint Agnes will continue to provide a wide array of hospital and non hospital based health care services, our Community Health initiatives identified through the CHNA reflect the most critical, pressing health need gaps. Description of Communities Served by Saint Agnes Hospital Due to its location in the southwest segment of the Baltimore Metropolitan Area, Saint Agnes serves a diverse patient population. Saint Agnes primary and secondary service areas (Southwest Baltimore City and Baltimore County, Northern Anne Arundel County, Eastern Howard County, and Southern Carroll County) have a population of approximately 738,000. The service area for study in the Community Health Needs assessment represents the zip codes that comprise 80% of Saint Agnes Hospital discharges, 60% of those discharges come from the primary service area, with the remaining 20% from the secondary service area. A map of the communities Saint Agnes serves is included in Attachment 1. Within the service area, Saint Agnes has defined eleven different communities. The communities are groupings of zip codes in the defined service area based on similar demographic characteristics and geographic boundaries. Details about each of the individual communities may be found in Attachment 2. Who was Involved in the Assessment The assessment process involved both quantitative and qualitative components. Saint Agnes engaged the participation of key internal and external stakeholders who represent the broad interest of the communities served by Saint Agnes to review the quantitative analysis. The stakeholders provided input through a structured online survey and via focus groups across the assessment process during late Fiscal Year 2012 and early Fiscal Year 13. The stakeholders were individuals with expertise in provision of health care services and public health and included community leaders, physicians, nursing, social work, pastoral care, care management, emergency outpatient and management representatives. A list of CNHA participants is included in Attachment 3.
Saint Agnes met with the Health Officer and senior leadership team of the Baltimore City Health Department in July 2012 to review the preliminary findings of the Community Health Needs Assessment and discuss the shared health priorities between the Saint Agnes assessment and the Baltimore City assessment as noted in the publication, Healthy Baltimore 2015. How the Assessment was Conducted Saint Agnes conducted its CHNA in two phases. The first phase was a quantitative assessment utilizing readily available secondary data sources to analyze 26 indicators of health status. An index of community health indicators definitions and sources is included in Attachment 4. Similar to the methodology utilized by the Robert Wood Foundation and the University of Wisconsin Population Health Institute in their County Health Ranking project, each of the eleven communities within the Saint Agnes service area was compared to Central Maryland average for each indicator to identify critical community health gaps. Within each community, if the health status for each indicator that was at least 10% worse than the Central Maryland average it was flagged as a potential critical health needs gap (red light). The 26 health indicators were grouped into 4 categories: 1. Demographic and socio economic characteristics, 2. Lifestyle & behavioral factors, 3. Co morbid precursor diagnoses, and 4. Major disease diagnoses In addition to the health indicator profiles, Saint Agnes reviewed the Community Health Plans of the local health jurisdictions including Baltimore City and Anne Arundel, Baltimore, Carroll, and Howard Counties. In addition, Saint Agnes is an active participant of the Community Health Planning Task Force for Baltimore City and Baltimore County. The information from the local health jurisdictions was included in the second phase of the CHNA process. The second phase of the assessment was a qualitative assessment utilizing internal and external stakeholders that represented the broad interest of the communities served and/or had expertise in health care services/public health. Stakeholders completed an online survey utilizing multiple techniques (top of mind, rank scaling, nominal group) to identify and prioritize community health needs. In addition to the online survey, stakeholders participated in focus group meetings. During the focus groups, the results of the qualitative assessment were shared as well as the results of the online survey and local health jurisdiction summaries. The result of the stakeholder focus groups was a recommendation to focus on the three most critical health priorities in Saint Agnes s community health improvement initiatives. Health Needs Identified During the community health needs assessment process, a broad range of health needs emerged. Twenty eight community needs were identified in total. These covered the spectrum from direct healthcare related needs, such as Primary Care Access, to non healthcare needs that affect a population s health status, like Literacy Education. A detailed list of all health needs identified in the process may be found in Attachment 5. The health status and subsequent needs of the populations analyzed vary widely by community; with similar communities demonstrating thematically comparable health needs. In the older, urban communities Saint Agnes serves, the Socio Economic/Vulnerable Population and indicators pose an elevated concern compared to other communities assessed. Communities vulnerable in these areas have a larger proportion of the population at risk due to their age (less than five years or greater than 65 years), have a lower level of education and income and have less access to primary care. In these same communities,
the Lifestyle/Behavior indicators are all red, demonstrating significant risk. Communities demonstrating needs in these areas reflect health needs associated with issues such as obesity, tobacco use and insufficient prenatal care. Arbutus, Catonsville, Glen Burnie and Woodlawn each show an overall health status on par with the Central Maryland Average, however the risk level for particular indices indicates that gaps exist in communities that do not have an overall unfavorable health status. Communities with aging populations such as South Carroll and Pasadena, show greater risk for the Major Disease Index, Joint & Spine Procedures. The summary of community health indicator profiles provides detail of each community s health risks in Attachment 6. Saint Agnes Hospital is one of among a dozen hospital providers that currently meet the majority of the acute health care needs of the defined service area in this assessment. These hospital providers include Johns Hopkins Health, University of Maryland Health System, and LifeBridge Health, Mercy Medical Center and Bon Secours Hospital. In addition to the hospital providers there is a wide array of other community resources including Federally Qualified Health Centers, faith based church communities, schools, and various private and public social service agencies that are available to address the health needs of the community independently and/or in partnerships with the area health systems. As noted, Saint Agnes participates in several forums such as the Baltimore City Health Improvement Planning Council, the Baltimore County Health Coalition, and the West Baltimore Primary Care Access Coalition. Each of these forums provides an opportunity for the vast array of community resources to connect and jointly address community health initiative priorities. Communities Health Needs Priorities: The process of the assessment utilized quantitative and qualitative data analysis to identify and prioritize community health needs. The prioritization process utilized multiple techniques such as online survey and stakeholder focus groups which employed top of mind, rank scaling, open end response, and nominal group technique to achieve consensus prioritization of most critical community health needs. The following health needs and geographies were identified as priority areas toward which Saint Agnes should focus its efforts: The priority needs identified were: 1. Obesity & Related Conditions 2. Cardiovascular Disease 3. Access/Linkages to Primary Care, especially to the poor and vulnerable populations Recognizing there are a wide variety of resources available to respond to the needs of the community, particularly the other hospital providers located in and around the Saint Agnes service area, in order to have the most impact Saint Agnes will focus community health initiatives in the communities of Southwest Baltimore City (21229), Catonsville (21228), and Arbutus (21227). How the Implementation Strategy Was Developed Following the identification of CHNA priorities, Saint Agnes solicited input from CHNA focus group participants as well as consulting with a variety of stakeholders including the Saint Agnes Foundation Board and the Baltimore City Health Department to share the assessment findings and discuss potential organizational response. In addition, Saint Agnes inventoried current community health activities to realign with new priorities, particularly within the Maryland Metabolic Institute and Cardiovascular Institute which have direct responsibility for two of the three identified priorities. The Community Health Need Assessment and Implementation Plan were reviewed and approved by the Saint Agnes Executive Leadership as well as the Planning Committee of the Board of Directors prior to review and approval by the Board of Directors.
Implementation Strategy Obesity and Related Chronic Conditions 1. Enhance the health status of Saint Agnes associates at risk for metabolic syndrome through participation in The Maryland Metabolic Institute's well4life program. 2. In collaboration with strategic partners, seek opportunities to contract with area employers to offer programs to improve the health status of the community workforce. 3. Explore opportunities to enhance access to bariatric surgery program through the Maryland Medicaid program. 4. Seek opportunities to engage with area middle and secondary schools to provide educational sessions regarding obesity and healthy lifestyle behaviors. 5. Explore opportunities to provide environments that enhance access to physical activity for the community as part of the Gibbons Commons master plan. 6. Seek and secure grant opportunities that facilitate Saint Agnes's ability to enhance and expand obesity education, screening, and treatment services. Cardiovascular Disease 1. Enhance and expand the foundation of education and screening services established with Saint Agnes's Red Dress Sunday and other initiatives to raise the community s awareness and knowledge of cardiovascular disease as well as an individual s own personal risk factors. 2. Support Baltimore City Health Department's Healthy Baltimore 2015 priority to promote heart health so as to reduce the impact of cardiovascular disease, the leading cause of death in Baltimore City. 3. Renovate acute care facilities of the Cardiovascular Institute to facilitate the adoption of a collaborative clinical practice model that better integrates all aspects of the multidisciplinary care team to improve patient outcomes. 4. Maintain Certificate of Ongoing Performance for primary and non primary angioplasty programs to ensure that citizens of West Baltimore, particularly disenfranchised individuals continue to have access to interventional cardiovascular services. 5. Seek and secure grant opportunities that facilitate Saint Agnes's ability to enhance and expand cardiovascular education, screening, and treatment services. Primary Care Access, Especially For Poor and Vulnerable 1. In conjunction with strategic partner, Baltimore Medical Systems, Inc., facilitate access to primary care services via the Federally Qualified Health Center located on Saint Agnes campus through expansion of the FAHC facilities and enhanced collaborative linkages with Saint Agnes services. 2. Establish a Health Enterprise Zone in West Baltimore through a collaborative partnership, the West Baltimore Primary Care Access Collaborative (WBPCAC). Support the mission of WBPCAC to create a sustainable, replicable system of care to reduce health disparities, improve access to health care, reduce costs, and expand primary care and community health workforce.
Next Steps The Board of Directors of Saint Agnes Hospital approved the Community Health Needs Assessment and Implementation Plan on February 25, 2013. Subsequent to that approval, Saint Agnes will publish the assessment on its website in accordance with the requirements that the assessment be made widely available to the public in the Spring of 2013. In addition, Saint Agnes will continue to reach out to the community leaders to share the results of the assessment as well as identified priorities as a mechanism to educate the community and identify strategic partners that can assist with addressing identified health needs. As Saint Agnes develops the FY14 18 Integrated Strategic Operational Financial Plan (ISOFP) as well as FY 14 Strategic Implementation Plan, the CHNA Implementation Plan will be integrated into those documents as well as into the relevant Institute strategic plans. To ensure appropriate accountability, initiatives within the CHNA implementation plan will be assigned to key executive leaders. Saint Agnes will continue to participate with the local health jurisdictions in the development of community health initiatives and alignment of shared objectives. Saint Agnes will also need to develop a CHNA performance report card including identification of metrics that reflect the community health status, particularly for the identified priorities.
Attachment 1: Service Area & Community Map Community Zoom View South Carroll Woodlawn W. Baltimore City Ellicott City S.W. Baltimore City y Catonsville S. Baltimore City Arbutus Brooklyn/Linthicum Glen Burnie B i Pasadena 6
Attachment 2: Community Profiles Arbutus (Zip Code 21227): Arbutus is an older suburban community, located south of Caton and Wilkens Avenues, and has a population of 33,139. The traditionally blue collar community is part of the Baltimore County Health Jurisdiction. Saint Agnes Hospital is the primary hospital provider best positioned to address the specific health needs of this community. Brooklyn Linthicum (Zip Codes 21090, 21225): Brooklyn Linthicum is an older urban/suburban community, located southeast of Caton and Wilkens Avenues, and has a population of 40,179. The industrial and blue collar community has seen an increase in the uninsured population and is part of both the Baltimore City and Baltimore County Health Jurisdictions. Harbor Hospital is the primary hospital provider best positioned to address the specific health needs of this community. Catonsville (Zip Code 21228): Catonsville is an older suburban community, located west of Caton and Wilkens Avenues, and has a population of 48,659, with a growing proportion of seniors. The traditionally white collar community is part of the Baltimore County Health Jurisdiction. Saint Agnes Hospital is the primary hospital provider best positioned to address the specific health needs of this community. Ellicott City (Zip Codes 21042, 21043, 21075): Ellicott City is a growing suburban community, located west/southwest of Caton and Wilkens Avenues, and has a population of 48,659. The predominantly white collar community is part of the Howard County Health Jurisdiction. Howard County General Hospital is the primary hospital provider best positioned to address the specific health needs of this community. Glen Burnie (Zip Codes 21060, 21061): Glen Burnie is an older suburban community, located west/southwest of Caton and Wilkens Avenues, and has a population of 75,243, with a growing proportion of seniors. The traditionally blue collor community is part of the Anne Arundel County Health Jurisdiction. Baltimore Washington Medical Center is the primary hospital provider best positioned to address the specific health needs of this community. Pasadena (Zip Code 21122): Pasadena is a suburban community, located southeast of Caton and Wilkens Avenues, and has a population of 58,941, with a growing proportion of seniors. The growing community is primarily served by Baltimore Washington Medical Center and is part of the Anne Arundel County Health Jurisdiction. Baltimore Washington Medical Center and Anne Arundel Medical Center are the primary hospital providers best positioned to address the specific health needs of this community. South Baltimore City (Zip Code 21223, 21230): South Baltimore City is an older urban community, located east/southeast of Caton and Wilkens Avenues, and has a population of 62,268. The urban community is projected to experience population declines. South
Baltimore City is part of the Baltimore City Health Jurisdiction. Baltimore Washington Medical Center is the primary hospital provider best positioned to address the specific health needs of this community. South Carroll (Zip Codes 21104, 21163, 21784): South Carroll is a suburban community, located northwest of Caton and Wilkens Avenues, and has a population of 52,287, with a growing proportion of seniors. The traditionally rural community has transitioned to a growing suburb of the Metro Baltimore Region. South Carroll is part of Carroll County Health Jurisdiction. Carroll County General Hospital and Northwest Hospital are the primary hospital providers best positioned to address the specific health needs of this community. Southwest Baltimore City (Zip Code 21229): Southwest Baltimore City is an older urban community, located at Caton and Wilkens Avenues, and has a population of 46,881. Similar to other urban areas, Southwest Baltimore is projected to experience population declines. Southwest Baltimore City is part of the Baltimore City Health Jurisdiction. Saint Agnes Hospital is the primary hospital provider best positioned to address the specific health needs of this community. West Baltimore City (Zip Code 21215, 21216, 21217): West Baltimore City is an older urban community, located north of Caton and Wilkens Avenues, and has a population of 134,531. Similar to other urban areas, West Baltimore is projected to experience population declines. West Baltimore City is part of the Baltimore City Health Jurisdiction. Sinai Hospital, University of Maryland and Bon Secours Hospital are the primary hospital providers best positioned to address the specific health needs of this community. Woodlawn (Zip Code 21207, 21244): Woodlawn is a suburban community, located northwest of Caton and Wilkens Avenues, and has a population of 83,180, with a growing proportion of seniors. Woodlawn is part of the Baltimore County Health Jurisdiction. Northwest Hospital is the primary hospital provider best positioned to address the specific health needs of this community.
Attachment 3: Community Health Needs Assessment Participants Saint Agnes Hospital has a long standing history of conducting community health needs assessments having conducted the first formal assessment in the early 1990s. Since that time, Saint Agnes has established many relationships with members of the physician medical community, community leaders, and former governance leaders that have specialized knowledge of health and the defined community or expertise in public health. For example, Dr. Raymond Bahr, a retired member of the Saint Agnes medical staff, is a world renowned expert in community education and early intervention to reduce the incidence of death as a result of heart attack. Saint Agnes was fortunate to have the following individuals participate in the assessment process due to their strong knowledge of our community and the health industry, their specialized medical or public health expertise, or because of their position within the organization were able to represent the needs of the medically underserved, low income, and minority populations, and those with chronic disease health needs. Community Representatives: Raymond Bahr, MD, community representative, cardiologist Kenneth Bancroft, community representative, former hospital CEO Barbara Bozzuto, community representative, former member & chair hospital Board of Directors Alan Reisinger, MD, community representative, primary care physician Thelma Daley, PhD, community representative, former member hospital Board of Directors Ron Kaufman, community representative, former member hospital Board Planning Committee Stephen Plantholt, MD, community representative, cardiologist Frank Ryan, community representative, former member hospital Board of Directors Adil Totoonchie, MD, community representative, general surgeon, former member hospital Board of Directors Oxiris Barbot, MD, Health Officer, Baltimore City Health Department Saint Agnes Hospital: Shadi Barakat, MD, Medical Director Diabetes Center Paul McClelland, MD, Psychiatrist Richard Pomerantz, MD, Chairman Department of Medicine Carole Miller, MD, Medical Director Cancer Institute Michael Burke, MD, Chairman Department of Pediatrics James Richardson, MD, Section Chief Geriatric Medicine Michael Lantz, MD, Interim Chairman Department of OB/GYN Deborah Som, MD, Associate Program Director Baltimore Medical Systems Daniel Hardesty, MD, Physician Advisor Care Management Kirstan Cecil, Director of Marketing & Communications Cathy Carr Dardin, RN, Bariatric Surgery Nurse Coordinator Kim Fabian, Director Maryland Metabolic Institute Peggy Lanasa, RN, Community Outreach Nurse Morrell Park Wellness Center Karen Reichert, RN, Nursing Director Maternal Child Health Shirley Sutton, Director Managed Care and Government Relations Sr. Ellen LaCapria, DC, Vice President Mission Integration MaryKay Gardenier, Vice President Cardiovascular Institute & Clinical Support Services Nancy Mannion, RN, Clinical Unit Coordinator Preventive Cardiology Jerrilyn Spiegl, RN, Clinical Operations Manager Cancer Institute Mary Austin, Assistant Vice President Cancer Institute Carolyn Moore, Director Rehabilitation Services Donna Hall, RN, Director Care Management Jennifer Broaddus, LCSW C, OSW C, Social Worker Cancer Institute Chaplain Ann Hazelwood, Dmin, Director Spiritual Care Susan Dove, RN, Nursing Director Emergency Department
Attachment 4: Community Health Indicators, Definitions & Sources Socio-Economic / Vulnerable Population What degree of vulnerability exists with regards to greater health care needs, or greater disparities in access to health care? These indicators identify vulnerable populations, such as age groups which have a higher propensity to utilize healthcare, as well as those which are more likely to experience financial barriers and disparities in access to health care. Age Under 5; Age 65+ Diversity Uninsured High School Diploma/Less Primary Care Access Low Income Households How prevalent are certain lifestyle choices and behavior patterns, which are highly correlated to increased risk of developing health-related complications and co-morbid conditions? Lifestyle / Behavior Co-Morbid Conditions These indicators identify lifestyle choices and behavioral patterns which increase the risk of developing co-morbid conditions. Metrics such as behavioral health, substance abuse and HIV can be predictive of overall health status. t Obesity Behavioral Health HIV Positive Insufficient Prenatal Care Substance Abuse Tobacco Use How prevalent are co-morbid conditions, which indicate greater risk of developing major disease, and how well are these conditions managed? These indicators identify the prevalence of co-morbid conditions which are often precursors to major disease. High ambulatory sensitive admission rates may indicate poor access or inadequate health care management. Arthritis Joint & Back Pain Asthma Chronic Bronchitis Diabetes Hypertension Ambulatory Sensitive Admissions Major Disease How prevalent are major diseases, which require high levels of care and intensive health services? These indicators identify the prevalence l of major disease which h require high h levels l of care and intensive i health services. A high prevalence of major disease represents a significant degree of health need, in a community. Cancer Cardiovascular Coronary Heart Disease Joint & Spine Procedures Coronary Heart Failure Heart Attack Stroke Infant Mortality 10
Attachment 4: Community Health Indicators, Definitions & Sources Socio-Economic/Vulnerable Pop. Definition Age Under 5 2010 Census Data; Thomson Reuters - Claritas 2010* Age 65+ 2010 Census Data; Thomson Reuters - Claritas 2010* High School Diploma/Less Highest achieved education for population age 25+; Thomson Reuters Diversity Non-Caucasian population, 2010 Census Data; Thomson Reuters - Claritas 2010 Primary Care Access Age 18+ Percent of population with a personal physician; Thomson Reuters - Regionally adjusted survey responses Uninsured Uninsured population, 2010 Census Data; Thomson Reuters - Claritas 2010 Low Income Households Household Income 200% above the 2010 poverty level for a household of 4; Thomson Reuters - Claritas 2010 Lifestyle/Behavior Index Obesity Admissions per 1000 population, Maryland Inpatient Discharge Data, ICD-9 Dx Codes 278-278.01; MSA 2010** Behavioral Health Admissions per 1000 population, Maryland Inpatient Discharge Data, MDC 19; MSA 2010** HIV Positive Admissions per 1000 population, Maryland Inpatient Discharge Data, ICD-9 Dx Code 042; MSA 2010** Insufficient Prenatal Care Admissions per 1000 population, Maryland Inpatient Discharge Data, ICD-9 Dx Code V23.7; MSA 2010** Substance Abuse Admissions per 1000 population, Maryland Inpatient Discharge Data, MDC 20; MSA 2010** Tobacco Use Admissions per 1000 population, Maryland Inpatient Discharge Data, ICD-9 Dx Code 305.1; MSA 2010** Co-Morbid Conditions Index Arthritis Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Back and Joint Pain Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Asthma Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Chronic Bronchitis Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Diabetes Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Hypertension Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Ambulatory Sensitive Admissions Maryland Inpatient Discharge Data, Asthma (Dx 493-493.9), Diabetes (Dx 249-250.9) and Hypertension (Dx 401-405); MSA 2010** Major Disease Index Cancer Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Cardiovascular Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Coronary Heart Disease Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Coronary Heart Failure Prevalence per 100 population, regionally adjusted d estimates, t National Health Interview Survey; Thomson Reuters 2010 Heart Attack Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Stroke Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Joint & Spine Procedures Maryland Inpatient Discharge Data, ICD-9 Proc Codes.70-.73;.80-.85; 3.09; 80.51; 81.00-81.08; 81.30-81.39; 81.51-81.55 Infant Mortality Maryland Inpatient Discharge Data, ICD-9 Dx Code 656.4; MSA 2010** Cancer - Gyn Prevalence per 100 population, regionally adjusted estimates, National Health Interview Survey; Thomson Reuters 2010 Sources Market Expert; Thompson Reuters **MSA 2010; Market Share Analyst, St. Paul Computer Center; Maryland Inpatient Discharge Data 11
Attachment 5: Health Needs Identified and Priority Needs Not Being Addressed The community health needs assessment process surfaced a wide range of needs in the communities which Saint Agnes serves. In accordance with the criteria outlined in the Health Care Affordability Act and 501(r)(3) regulatory requirements, Saint Agnes developed an implementation strategy to address the most critical of health needs and geographies. While a focused number of community health needs and response initiatives are addressed in the implementation strategy, Saint Agnes will continue to offer its full spectrum of services to those whom seek care. For communities in which Saint Agnes is not the primary hospital provider; the primary provider is better positioned to address their community s health needs. Non healthcare areas for which Saint Agnes does not have the requisite knowledge or expertise to address the needs, other community organizations will be better positioned to address these needs. Cardiovascular Disease Community Health Need Obesity & Related Chronic Diseases Primary Care Access Asthma Behavioral Health Services Cancer Community Care Management/ Care Coordination General Community Outreach HIV Medication/Treatment Plan Compliance Special care needs for Children Special care needs for Immigrant Populations Saint Agnes CHNA Implementation Plan Objective CHNA Priority as a critical community health need. Specific objectives to address identifed community health need are included in CHNA Implementation and will be coordinated through the Saint Agnes Cardiovascular Institute. CHNA Priority as a critical community health need. Specific objectives to address identifed community health need are included in CHNA Implementation and will be coordinated through the Saint Agnes Maryland Metabolic Institute. CHNA Priority as a critical community health need, with special attention to the primary care needs of poor and vulnerable populations. Specific objectives to address identifed community health need are included in CHNA Implementation and will be coordinate through Saint Agnes's primary care group, Seton Medical Group, and with other strategic partnerships. This need was not identified/prioritized as a critical community health need. Saint Agnes response will be provided through physician and hospital services to asthma patients seeking care at Saint Agnes. This need was not identified/prioritized as a critical community health need. Due to State Health Plan regulations, Saint Agnes does not currently provide behavioral health continuum of care and other providers in the community are better positioned to address this need. This need was not identified/prioritized as a critical community health need. Saint Agnes offers inpatient and outpatient oncology services through its Cancer Institute for patients seeking care at Saint Agnes. This need was not identified/prioritized as a critical community health need. Saint Agnes will provide limited community based care management services via demonstration projects within readmission reducation initiative. This need was not identified/prioritized as a critical community health need. Community outreach will focus within three identified critical health needs which include cardiovascular disease, obesity & related chronic conditions, and primary care access. This need was not identified/prioritized as a critical community health need. Saint Agnes response will be provided through physician and hospital services to HIV patients seeking care at Saint Agnes. This need was not identified/prioritized as critical community health need. Saint Agnes will provide limited medication treatment plan compliance as part of care management services via demonstration projects within readmission reducation initiative. This need was not identified/prioritized as critical community health need. Saint Agnes offers a wide array of physician, outpatient, emergency and inpatient services through the Bunting Institute for Women and Children for patients seeking care at Saint Agnes. This need was not identified/prioritized as a critical community health need. Saint Agnes offers a wide array of physician, outpatient, emergency and inpatient services to meet the health needs of immigrants seeking care at Saint Agnes.
Attachment 6: Service Area Health Risk Summary by Community Service Area Health Risk Summary by Community Community Health Indicators Socio-Economic / Vulnerable Pop. Central Maryland Average Percent of Population Age Under 5 6.5% Age 65+ 12.8% High School Diploma/Less 40.0% Diversity 40.7% Primary Care Access Age 18+ 86.9% Uninsured 16.3% Low Income Households 34.4% Overall Index Score Arbutus Brooklyn/ Ellicott Glen Catonsville Linthicum City Burnie Pasadena South Baltimore City South Carroll Southwest Baltimore City West Baltimore City Woodlawn Rate per 1,000 Lifestyle/Behavior Index Population Obesity 19.58 Behavioral Health 7.61 HIV Positive 2.18 Insufficient Prenatal Care 3.84 Substance Abuse 2.69 Tobacco Use 23.05 Overall Index Score Co-Morbid Conditions Index Rate per 100 Population Arthritis 17.30 Back and Joint Pain 21.53 Asthma 9.17 Chronic Bronchitis 3.07 Diabetes 6.65 Hypertension 23.47 Ambulatory Sensitive Admissions 1.51 Overall Index Score Rate per 100 Major Disease Index Population Cancer 0.49 Cardiovascular 2.46 Stroke 2.22 Joint & Spine Procedures 0.60 Infant Mortality 0.43 Cancer - Gyn 0.57 Overall Index Score Summary Need Index Index Definition A community health indicator which measures exactly at the Central Maryland average is represented by an index score of 1.00. The extent to which a community health indicator is favorable, or unfavorable, to the Central Maryland average is represented by an index score below 1.00, or above 1.00, respectively. The "stoplight" signals correspond to index scores as noted to the right. Signal Mild Risk Moderate Risk High Risk Index Score <1.05 1.05 to 1.10 >1.10 14
Attachment 6: Service Area Health Risk Summary by Community Health Index Summary Community Zip Codes Population SAH Market Share SAH Dependence Vulnerable Population Index Lifestyle Behavior Index Co-Morbid Conditions Index Major Disease Index Overall Health Index West Baltimore City 21215, 21216, 21217 134,531 5.0% 7.1% 1.67 2.49 1.21 1.01 1.60 South Baltimore City 21223, 21230 62,268 13.5% 8.6% 1.45 2.30 1.19 0.77 1.43 Brooklyn/Linthicum 21090, 21225 40,179 5.9% 2.4% 1.30 1.74 1.13 1.35 1.38 Southwest Baltimore City 21229 46,881 42.1% 18.2% 1.44 1.44 1.15 0.91 1.24 Woodlawn 21207, 21244 83,180 11.6% 6.9% 1.16 1.02 1.04 0.86 1.02 Arbutus 21227 33,139 45.6% 12.8% 1.04 1.00 0.98 0.94 0.99 Glen Burnie 21060, 21061 75,243 3.1% 1.8% 0.98 0.88 1.00 1.02 0.97 Catonsville 21228 48,659 54.7% 18.6% 0.90 0.57 1.05 1.11 0.91 South Carroll 21104, 21163, 21784 52,287 4.1% 1.0% 0.67 0.36 0.92 1.16 0.78 Ellicott City 21042, 21043, 21075 102,415 13.0% 5.0% 0.67 0.30 0.85 0.90 0.68 Pasadena 21122 58,941 3.0% 1.0% 0.72 0.54 0.93 0.97 0.63 The communities included in this health needs assessment represent the Saint Agnes Hospital primary and secondary service areas. The assessment compares 35 community specific health indicators, against Central Maryland averages. The extent to which a community is at higher than average risk, for a specific indicator, the index score will exceed 1.00. The inverse is true for an index scores below 1.00, which indicates a comparatively lower level of health risk. The overall health index, which is an average of all community need indices, highlights those communities with the greatest healthcare needs in the Saint Agnes Hospital service area. This assessment has identified that the more urban based communities of West Baltimore City, South Baltimore City, Brooklyn/Linthicum and Southwest Baltimore City represent the greatest healthcare needs, each with overall indices exceeding 1.30. The suburban communities of Pasadena, Ellicott City and South Carroll have comparatively fewer healthcare needs, as determined by this assessment. Community needs, market share and community dependence rates, suggest that Saint Agnes Hospital can make the greatest impact in Southwest Baltimore City. 15
Attachment 6: Service Area Health Risk Summary by Community Index Scores Community Age < 5 Age 65+ Socio-Economic/Vulnerable Population Edu. < High School Diversity Primary Care Access Uninsured Low Income Households Arbutus 1.09 1.03 1.42 0.68 0.96 0.90 1.18 Brooklyn/Linthicum 1.14 1.13 1.56 0.90 0.95 1.97 1.45 Catonsville 0.87 1.44 0.82 0.92 0.80 0.58 0.86 Ellicott City 1.01 0.80 0.52 0.80 0.78 0.31 0.44 Glen Burnie 0.99 1.02 1.32 0.77 1.02 0.75 0.98 Pasadena 1.01 0.89 1.16 0.27 0.85 0.34 0.51 S. Balt City 1.17 0.88 1.54 1.30 1.22 2.43 1.61 South Carroll 0.96 0.95 0.78 0.37 0.86 0.26 0.48 SW Balt City 1.18 1.03 1.33 1.96 1.09 1.92 1.57 W Balt City 1.20 1.11 1.45 2.19 1.26 2.67 1.82 Woodlawn 1.14 0.85 1.02 2.16 0.94 0.85 1.19 Grand Total 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Lifestyle Behavior Index Community Obesity Behavioral Health HIV Positive Insufficient Prenatal Care Substance Abuse Tobacco Use Arbutus 1.31 0.72 0.24 1.27 1.12 1.34 Brooklyn/Linthicum 2.26 1.52 1.22 1.31 1.90 2.24 Catonsville 0.78 0.61 0.25 0.56 0.56 0.64 Ellicott City 0.38 0.36 0.04 0.49 0.24 0.28 Glen Burnie 1.41 1.05 0.30 0.34 0.82 1.36 Pasadena 0.90 0.58 0.07 0.22 0.59 0.85 S. Balt City 1.54 2.11 3.14 1.73 2.63 2.63 South Carroll 0.64 0.59 0.05 0.13 0.27 0.46 SW Balt City 1.41 1.14 2.11 1.11 1.29 1.57 W Balt City 1.70 2.24 4.43 2.45 1.96 2.16 Woodlawn 1.24 0.96 1.17 1.25 0.66 0.83 Grand Total 1.00 1.00 1.00 1.00 1.00 1.00 16
Attachment 6: Service Area Health Risk Summary by Community Index Scores Co-Morbid Conditions Index Community Arthritis Ambulatory Back and Chronic Asthma Diabetes Hypertension Sensitive Joint Pain Bronchitis Admissions Arbutus 0.98 1.00 0.99 1.01 0.87 0.93 1.11 Brooklyn/Linthicum 103 1.03 100 1.00 098 0.98 102 1.02 098 0.98 100 1.00 190 1.90 Catonsville 1.15 1.07 1.02 1.06 1.11 1.12 0.86 Ellicott City 0.91 0.95 0.95 0.94 0.90 0.89 0.40 Glen Burnie 0.98 1.00 1.00 1.00 0.92 0.94 1.12 Pasadena 1.01 1.03 1.01 1.06 0.85 0.91 0.63 S. Balt City 0.93 0.96 0.99 0.95 1.01 0.99 1.81 South thcarroll 103 1.03 103 1.03 099 0.99 104 1.04 089 0.89 094 0.94 050 0.50 SW Balt City 0.98 0.94 0.98 0.93 1.23 1.13 1.88 W Balt City 0.99 0.93 0.97 0.91 1.34 1.19 2.15 Woodlawn 0.90 0.90 0.97 0.88 1.18 1.09 1.34 Grand Total 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Major Disease Index Community Cancer Cardiovascular Stroke Joint & Spine Procedures Infant Mortality Cancer-Gyn Arbutus 1.04 0.99 0.92 1.09 0.48 1.07 Brooklyn/Linthicum 107 1.07 106 1.06 102 1.02 128 1.28 259 2.59 107 1.07 Catonsville 1.26 1.26 1.27 1.16 0.46 1.24 Ellicott City 0.92 0.89 0.83 0.77 1.01 0.95 Glen Burnie 1.01 0.98 0.93 1.33 0.82 1.03 Pasadena 1.04 0.96 0.84 1.26 0.66 1.06 S. Balt City 0.87 0.90 0.97 0.76 0.25 0.88 South thcarroll 105 1.05 099 0.99 090 0.90 118 1.18 178 1.78 107 1.07 SW Balt City 0.85 0.98 1.19 0.90 0.74 0.84 W Balt City 0.84 1.01 1.28 0.84 1.33 0.78 Woodlawn 0.75 0.90 1.10 0.83 0.84 0.72 Grand Total 1.00 1.00 1.00 1.00 1.00 1.00 17